UNITED INDIA INSURANCE CO LTD vs Anumolu Rama Krishan

UNITED India Insurance Co. Ltd. (hereinafter referred to as the ''Petitioner '') has filed the present revision petition being aggrieved by the order of the State Consumer Disputes Redressal Commission, Hyderabad (hereinafter referred to as the ''State Commission '') in Appeal No.1447/2007 by which the State Commission upheld the order of the District Forum in favour of Anumolu Rama Krishna, Respondent herein who was the original complainant before the District Forum.

THE facts of the case are that the Respondent/Complainant had taken a medical insurance policy on 24.09.2001 from the Petitioner/Insurance Company for himself and his wife for the period 24.09.2001 to 23.09.2002. Subsequently, Respondent experienced some burning sensation and difficulty in breathing and on medical advice, he got himself admitted in Usha Mullapudi Hospital on 30.10.2001 where he was advised that a Coronary Artery Graft Bypass (CABG) surgery was required which he underwent. On completion of surgery, Respondent filed a claim with Petitioner/Insurance Company along with a discharge summary and medical bills etc. for Rs.2,20,076/-. After a lapse of one year the Petitioner/Insurance Company repudiated the claim on the grounds that the medical condition for which Respondent was operated existed prior to his taking the policy and therefore, he had suppressed material facts regarding his pre-existing diseases. Since, according to Respondent this was not factually correct and prior to taking the policy as required by the Petitioner/Insurance Company, he had got himself medically checked and Petitioner/Insurance Company were satisfied with his state of health before issuing the policy, the claim was wrongly repudiated. Respondent, therefore, filed a complaint before the District Forum on grounds of deficiency in service and requested that Petitioner/Insurance Company be directed to pay him Rs.2,90,000/- with interest @ 12% per annum from February, 2002 till realization, Rs.25,000/- towards mental agony and harassment and any other relief which the Forum may deem appropriate. The District Forum after hearing both parties and on the basis of evidence filed before it allowed the complaint on the ground that the Petitioner/Insurance Company on whom there was onus to do so had not been able to provide any credible evidence that the Respondent was suffering from any pre-existing disease or that he had knowledge of the same. District Forum after deducting Rs.8,100/- being room rent in the hospital, quantified the expenses incurred as Rs.2,11,976/- and directed the Petitioner/Insurance Company to pay this amount with interest @ 9% per annum from the date of filing of the complaint till realization within 30 days from the date of order.

AGGRIEVED by this order, Petitioner/Insurance Company filed an appeal before the State Commission which dismissed the same by observing as under: "It is pertinent to note from the discharge summary that the complainant had chest pain only for one week duration and that there is no history suggestive of MI in the past. Therefore, the contention of the Opposite Parties that he was suffering from CAB and was in the knowledge of this disease and deliberately suppressed it prior to issuance of the policy is unsustainable. Though the contention of Opposite Parties that CAD cannot be developed in a period of 45 days is reasonable but the Appellant/Opposite Parties failed to establish that this disease was in the knowledge of the life assured and that he deliberately suppressed it. The clinical record shows that the life assured had history of chest pain only for one week duration and that he had not previous history of any heart disease. Therefore, we see no reason to interfere with the well-considered order of the District Forum. "

HENCE , the present revision petition. Learned Counsel for both parties made oral submissions. Counsel for Petitioner stated that Petitioner/Insurance Company had appointed two investigators one after the other to investigate the claim and as per report received it came to light that the Respondent had diabetes and hypertension for the past 7 years and since these are chronic diseases and do not occur overnight, the Respondent by suppressing these facts, prior to his having taken the policy had breached the principle of utmost good faith on which an insurance policy is based and also the terms and conditions of the policy. Therefore, the claim was rightly repudiated.

COUNSEL for Respondent contended that the Fora below had rightly concluded that no evidence had been produced by the Petitioner/Insurance Company on whom there was onus to do so that the Petitioner had suppressed any material facts regarding his pre-existing disease. In fact, Respondent did not have any medical complaints and was in good health prior to his having taken the insurance policy and it was only thereafter that he experienced chest pain for about a week and was diagnosed with unstable angina. These facts are also recorded in the clinical summary of the hospital where Respondent underwent the CABG procedure. The claim was wrongly repudiated and therefore, the revision petition deserves to be dismissed.

WE have heard learned Counsel for both parties and have gone through the evidence on record. The fact that the Respondent underwent CABG surgery on 08.11.2001, which is after his having taken the insurance policy, is not in dispue. We have gone through the clinical summary of the hospital where he underwent the above surgery and it is clearly indicated therein that there was no history suggesting MI and the history of chest pain was of only one week ''s duration. It is also on record that the patient was issued the medical insurance policy after he underwent a medical test which also did not indicate that he was suffering from the above diseases. Petitioner/Insurance Company on whom there was onus to prove otherwise has been unable to do so. For example, Petitioner/Insurance Company has not been able to produce any record or evidence from any hospital or medical practitioner that the patient had undergone treatment for these ailments prior to his having taken the insurance policy. Even if Respondent was suffering from these diseases which admittedly do not occur overnight, it is both possible and plausible that he was unaware of it since these can be "silent diseases " and a person suffering from them may not even be aware until the condition aggravates and overt symptoms appear. In the instant case, as stated above, no evidence has been produced by Petitioner that the Respondent was aware of or had taken treatment for these diseases. Keeping in view these facts, we see no merit in this revision petition and dismiss the same. The orders of the Fora below are upheld. Petitioner/Insurance Company is directed to pay the Respondent Rs.2,11,976/- with interest @ 9% per annum from the date of filing of the complaint till realization within six weeks from the date of receipt of this order.